Operative note 31 Advanced
RPLND
What it does: node clearance behind the bowel, for testis cancer.
- Role / scope Type 1: template, nerve sparing, no known spread.
- Role / scope Type 2: small known nodes.
- Role / scope Type 3: post-chemo lumps. May need vessel grafts.
- Midline, breastbone to pubis.
- Peritoneum opened inside the mesenteric vein, up to Treitz. Right colon + small bowel bagged onto the chest. Guard the SMA artery. Slings on both ureters = side limits.
- "Split and roll": clear the left renal vein. Cut adrenal, gonadal and lumbar branches off it.
- Split node fat down the FRONT of IVC and aorta, right on the wall.
- Roll each leaf off. Cut lumbar vessels as met.
- Clear front and back of both great vessels.
- Clip every lymph leak.
Templates (learn these)
- RIGHT tumour: right hilum, down the ureter to the iliac, up the aorta (right of the IMA artery) to the left renal artery, back to the right hilum. 3 in 10 positive nodes hide BEHIND the vessels.
- LEFT tumour: renal vein to IMA, down the aorta's right edge, across at the iliac, up the ureter to the renal vein. Does not cross the midline.
- Watch: Extra renal arteries: 1 in 5.
- Watch: Left renal vein behind the aorta: 2-3 in 100.
- 2026 update: Europe: watch, or 1 cycle chemo, before RPLND.
- 2026 update: Robotic RPLND exists in big centres.
- 2026 update: Templates unchanged. Still the exam core.
From the UroRef Operative Quick Guide.